The goal of this observational study is to learn whether a brain-computer interface (BCI)-based attention training program, used alone or together with medication, can improve attention, executive functioning, and emotional regulation in school-age children with attention difficulties.

The study focuses on school-age children who were referred for problems with attention, concentration, or related cognitive and emotional difficulties.

The main questions it aims to answer are:

Does BCI-based attention training improve children's attention and response control when used on its own?

Do children show greater improvements when BCI-based attention training is combined with medication such as methylphenidate or citicoline?

Are there differences in attention, executive functioning, or emotional symptoms between children receiving combined approaches versus single treatments?

Researchers compared four naturally occurring treatment approaches to see whether combining attention training with medication leads to better outcomes than using one method alone.

Participants will:

Take part in a computerized, game-based BCI attention training program that uses brain signals to guide training tasks

Receive medication (methylphenidate or citicoline) if this was part of their usual clinical care

Complete computerized attention tests that measure focus, reaction time, and impulse control

Have parents complete questionnaires about attention, behavior, emotions, and everyday executive functioning before and after the intervention

This study was conducted in a real-world clinical setting and reflects routine treatment choices made by families and clinicians, rather than random assignment. The findings aim to help families and health care providers better understand how different treatment combinations may support attention and self-regulation in children.

Attention difficulties in childhood, including problems with sustained focus, impulse control, and executive functioning, are common reasons for referral to child and adolescent mental health services. While stimulant medications such as methylphenidate are widely used and effective for many children, not all families prefer medication alone, and some children continue to experience cognitive or emotional difficulties despite treatment. For these reasons, there is growing interest in non-pharmacological and combined approaches that target attention through different mechanisms.

One emerging approach is brain-computer interface (BCI)-based attention training. These programs use real-time brain signals, recorded through EEG sensors, to adapt game-like tasks that encourage sustained attention and cognitive control. Unlike traditional computer games, task difficulty and progression change dynamically based on the child's level of attentional engagement. This makes training more interactive and potentially more closely linked to underlying brain processes involved in attention regulation.

In routine clinical practice, some children receive BCI-based attention training alone, while others use it together with medication such as methylphenidate or citicoline. Citicoline is a nutritional supplement that has been suggested to support brain function and cognitive processes, although evidence in children remains limited. How these different approaches compare with one another, and whether combining them offers added benefit, is still not well understood.

This study was conducted in a naturalistic clinical setting, meaning that treatment choices were made as part of usual care rather than through random assignment. Children were grouped based on the intervention they received: BCI-based attention training alone, BCI combined with methylphenidate, BCI combined with citicoline, or citicoline alone. All children completed standardized assessments before and after the intervention period.

Attention and cognitive performance were evaluated using a computerized continuous performance test that measures sustained attention, reaction time, variability of responses, and impulse control. In addition, parents completed validated questionnaires assessing attention-related symptoms, emotional difficulties, and everyday executive functioning such as planning, inhibition, and emotional regulation.

By examining changes within each treatment group and comparing overall patterns across groups, this study aims to provide clinically meaningful information about how different treatment strategies may support attention and self-regulation in children. The findings are intended to help families and health care providers make more informed decisions about combining digital attention training with medication in real-world clinical settings.

Inclusion Criteria:

School-age children (approximately 6-18 years)

Clinical diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD)

Presence of attention or executive-function difficulties requiring clinical follow-up

Participation in one of the routine clinical interventions (BCI-based attention training, methylphenidate, citicoline, or their combination)

Completion of baseline and post-intervention assessments

Written informed consent obtained from a parent or legal guardian

Exclusion Criteria:

Presence of a neurological disorder (e.g., epilepsy, traumatic brain injury)

Intellectual disability or severe developmental disorder that would prevent participation in computerized assessments

Current use of additional psychotropic medications other than methylphenidate

Significant sensory or motor impairment interfering with computer-based testing

Incomplete assessment data or inability to complete the intervention period

The study population consists of school-age children referred to a child and adolescent psychiatry outpatient clinic due to attention-related difficulties. All participants have a clinical diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD) and were receiving routine clinical care at the time of enrollment. The population reflects a real-world clinical sample, including children with varying levels of attentional, executive-function, and emotional difficulties commonly observed in pediatric ADHD. Treatment selection was based on usual clinical decision-making rather than random assignment.

Individual participant data will not be shared, as the data were collected in a naturalistic clinical setting and include sensitive health information. De-identified aggregate data may be reported in publications.